Association between polymorphisms of immune response genes and early childhood caries - systematic review, gene-based, gene cluster, and meta-analysis

BACKGROUND

Early childhood caries is a significant public health concern affecting about 600 million children globally. The etiology of early childhood caries can be explained as an interplay between genetic and environmental factors. Single nucleotide polymorphisms are the most common variations in the human genome. Genetic variations of immune response genes can modify the defense response of the host, and alter the susceptibility to bacterial colonization of the oral cavity and early childhood caries. The aim of this systematic review is to identify genetic variants of immune response genes associated with early childhood caries.

RESULTS

A total of 7124 articles were identified by conducting an elaborate search across various electronic databases and genome-wide association studies databases. Subsequent to exclusion at various stages, fifteen articles qualified to be included into the present review. Risk of bias assessment was done with the Q-genie tool. Quantitative synthesis revealed that the odds ratio for TT and CC genotypes of rs11362 was 1.07 (0.67-1.71) and 1.16 (0.84-1.60), respectively. Gene-based analysis revealed a statistically significant association between variants of tumor necrosis factor-alpha gene and T-cell receptor alpha variable 4 locus with early childhood caries. Gene clustering showed the presence of three functional clusters. To comprehend the protein-protein interaction, the bioinformatic tool of "Search Tools for the Retrieval of Interacting Genes and Proteins" was used. Among the biological processes and the reactome pathways, complement activation through the lectin pathway showed the highest strength of association with early childhood caries. To understand the interaction and functionality of the genes, "gene function prediction using Multiple Association Network Integration Algorithm" was used, which revealed that the genes were linked by physical interaction (39.34%) and through co-expression (34.88%).

CONCLUSIONS

Genotype TT of rs7217186 of arachidonate 15-lipoxygenase gene was a risk factor for early childhood caries. Multiple genetic variants of T-cell receptor alpha variable 4 locus and tumor necrosis factor-alpha gene were associated with increased susceptibility to early childhood caries. Polymorphisms of genes regulating the lectin pathway of complement activation can modify the susceptibility to early childhood caries.

Analytical and Non-Analytical Variation May Lead to Inappropriate Antimicrobial Dosing in Neonates: An In Silico Study

BACKGROUND

Therapeutic drug monitoring (TDM) of aminoglycosides and vancomycin is used to prevent oto- and nephrotoxicity in neonates. Analytical and nonanalytical factors potentially influence dosing recommendations. This study aimed to determine the impact of analytical variation (imprecision and bias) and nonanalytical factors (accuracy of drug administration time, use of non-trough concentrations, biological variation, and dosing errors) on neonatal antimicrobial dosing recommendations.

METHODS

Published population pharmacokinetic models and the Australasian Neonatal Medicines Formulary were used to simulate antimicrobial concentration-time profiles in a virtual neonate population. Laboratory quality assurance data were used to quantify analytical variation in antimicrobial measurement methods used in clinical practice. Guideline-informed dosing recommendations based on drug concentrations were applied to compare the impact of analytical variation and nonanalytical factors on antimicrobial dosing.

RESULTS

Analytical variation caused differences in subsequent guideline-informed dosing recommendations in 9.3-12.1% (amikacin), 16.2-19.0% (tobramycin), 12.2-45.8% (gentamicin), and 9.6-19.5% (vancomycin) of neonates. For vancomycin, inaccuracies in drug administration time (45.6%), use of non-trough concentrations (44.7%), within-subject biological variation (38.2%), and dosing errors (27.5%) were predicted to result in more dosing discrepancies than analytical variation (12.5%). Using current analytical performance specifications, tolerated dosing discrepancies would be up to 14.8% (aminoglycosides) and 23.7% (vancomycin).

CONCLUSIONS

Although analytical variation can influence neonatal antimicrobial dosing recommendations, nonanalytical factors are more influential. These result in substantial variation in subsequent dosing of antimicrobials, risking inadvertent under- or overexposure. Harmonization of measurement methods and improved patient management systems may reduce the impact of analytical and nonanalytical factors on neonatal antimicrobial dosing.

Adaptation of a population pharmacokinetic model to inform tacrolimus therapy in heart transplant recipients

AIM

Existing tacrolimus population pharmacokinetic models are unsuitable for guiding tacrolimus dosing in heart transplant recipients. This study aimed to develop and evaluate a population pharmacokinetic model for tacrolimus in heart transplant recipients that considers the tacrolimus-azole antifungal interaction.

METHODS

Data from heart transplant recipients (n = 87) administered the oral immediate-release formulation of tacrolimus (Prograf®) were collected. Routine drug monitoring data, principally trough concentrations, were used for model building (n = 1099). A published tacrolimus model was used to inform the estimation of Ka , V2 /F, Q/F and V3 /F. The effect of concomitant azole antifungal use on tacrolimus CL/F was quantified. Fat-free mass was implemented as a covariate on CL/F, V2 /F, V3 /F and Q/F on an allometry scale. Subsequently, stepwise covariate modelling was performed. Significant covariates influencing tacrolimus CL/F were included in the final model. Robustness of the final model was confirmed using prediction-corrected visual predictive check (pcVPC). The final model was externally evaluated for prediction of tacrolimus concentrations of the fourth dosing occasion (n = 87) from one to three prior dosing occasions.

RESULTS

Concomitant azole antifungal therapy reduced tacrolimus CL/F by 80%. Haematocrit (∆OFV = -44, P < .001) was included in the final model. The pcVPC of the final model displayed good model adequacy. One recent drug concentration is sufficient for the model to guide tacrolimus dosing.

CONCLUSION

A population pharmacokinetic model that adequately describes tacrolimus pharmacokinetics in heart transplant recipients, considering the tacrolimus-azole antifungal interaction was developed. Prospective evaluation is required to assess its clinical utility to improve patient outcomes.

The psychological subtype of intimate partner violence and its effect on mental health: a systematic review with meta-analyses

PURPOSE

The present study examines the association between psychological violence and posttraumatic stress disorder (PTSD), depression, and anxiety, while comparing the specific subtypes of psychological violence and simultaneously focusing on methodological shortcomings.

METHOD

A systematic review and random-effects meta-analyses were applied on the three main outcomes: PTSD, depression, and anxiety. Four electronic databases were searched (PsycINFO, PubMed, EMBASE, and Web of Science), and a total of 194 studies were included (k = 149 for meta-analyses). GRADEpro was used to evaluate the certainty of the evidence from the meta-analyses.

RESULTS

Psychological violence had strong associations with the three main outcomes, with the strongest association for PTSD in both female and male victims. Coercive control was particularly associated with PTSD for female victims, while emotional/verbal and dominance/isolation had the strongest association with depression. Although the identified studies were characterized by gender bias, psychological violence appear to affect male mental health too.

DISCUSSION

Findings from the meta-analyses support the notion that psychological violence is a traumatic experience, which is strongly association with PTSD and other common mental health problems linked to trauma. GRADEpro rated the certainty of evince to be low, and thus, our confidence in the estimated effect is limited. Gender bias, the applied terminology, and other methodological shortcomings are discussed. Despite the substantial amount of research on this topic, more research is needed before we can draw any final conclusions on the effect of psychological violence on mental health.

Tacrolimus Therapy in Adult Heart Transplant Recipients: Evaluation of a Bayesian Forecasting Software

BACKGROUND

Therapeutic drug monitoring is recommended to guide tacrolimus dosing because of its narrow therapeutic window and considerable pharmacokinetic variability. This study assessed tacrolimus dosing and monitoring practices in heart transplant recipients and evaluated the predictive performance of a Bayesian forecasting software using a renal transplant-derived tacrolimus model to predict tacrolimus concentrations.

METHODS

A retrospective audit of heart transplant recipients (n = 87) treated with tacrolimus was performed. Relevant data were collected from the time of transplant to discharge. The concordance of tacrolimus dosing and monitoring according to hospital guidelines was assessed. The observed and software-predicted tacrolimus concentrations (n = 931) were compared for the first 3 weeks of oral immediate-release tacrolimus (Prograf) therapy, and the predictive performance (bias and imprecision) of the software was evaluated.

RESULTS

The majority (96%) of initial oral tacrolimus doses were guideline concordant. Most initial intravenous doses (93%) were lower than the guideline recommendations. Overall, 36% of initial tacrolimus doses were administered to transplant recipients with an estimated glomerular filtration rate of <60 mL/min/1.73 m despite recommendations to delay the commencement of therapy. Of the tacrolimus concentrations collected during oral therapy (n = 1498), 25% were trough concentrations obtained at steady-state. The software displayed acceptable predictions of tacrolimus concentration from day 12 (bias: -6%; 95%confidence interval, -11.8 to 2.5; imprecision: 16%; 95% confidence interval, 8.7-24.3) of therapy.

CONCLUSIONS

Tacrolimus dosing and monitoring were discordant with the guidelines. The Bayesian forecasting software was suitable for guiding tacrolimus dosing after 11 days of therapy in heart transplant recipients. Understanding the factors contributing to the variability in tacrolimus pharmacokinetics immediately after transplant may help improve software predictions.

Evaluation of published population pharmacokinetic models to inform tacrolimus dosing in adult heart transplant recipients

BACKGROUND AND AIM

Identification of the most appropriate population pharmacokinetic model-based Bayesian estimation is required prior to its implementation in routine clinical practice to inform tacrolimus dosing decisions. This study aimed to determine the predictive performances of relevant population pharmacokinetic models of tacrolimus developed from various solid organ transplant recipient populations in adult heart transplant recipients, stratified based on concomitant azole antifungal use. Concomitant azole antifungal therapy alters tacrolimus pharmacokinetics substantially, necessitating dose adjustments.

METHODS

Population pharmacokinetic models of tacrolimus were selected (n = 17) for evaluation from a recent systematic review. The models were transcribed and implemented in NONMEM version 7.4.3. Data from 85 heart transplant recipients (2387 tacrolimus concentrations) administered the oral immediate-release formulation of tacrolimus (Prograf) were obtained up to 391 days post-transplant. The performance of each model was evaluated using: (i) prediction-based assessment (bias and imprecision) of the individual predicted tacrolimus concentration of the fourth dosing occasion (MAXEVAL = 0, FOCE-I) from 1-3 prior dosing occasions; and (ii) simulation-based assessment (prediction-corrected visual predictive check). Both assessments were stratified based on concomitant azole antifungal use.

RESULTS

Regardless of the number of prior dosing occasions (1-3) and concomitant azole antifungal use, all models demonstrated unacceptable individual predicted tacrolimus concentration of the fourth dosing occasion (n = 152). The prediction-corrected visual predictive check graphics indicated that these models inadequately predicted observed tacrolimus concentrations.

CONCLUSION

All models evaluated were unable to adequately describe tacrolimus pharmacokinetics in adult heart transplant recipients included in this study. Further work is required to describe tacrolimus pharmacokinetics for our heart transplant recipient cohort.

P–558 SNP array versus karyotype for prenatal diagnosis in fetuses with abnormal ultrasound: a systematic review and meta-analysis

Study question

Does Single nucleotide polymorphism (SNP) array provide a diagnostic advantage over conventional karyotype in prenatal diagnosis for fetuses with an abnormal ultrasound?

Summary answer

SNP array in the prenatal setting provides an incremental diagnostic yield over karyotype and the diagnostic accuracy is comparable with combined SNP array and karyotype

What is known already

Single nucleotide polymorphism and comparative genomic hybridization based arrays (aCGH) are the two chromosomal microarray (CMA) platforms available. Guidelines which recommend offering CMA instead of karyotyping for prenatal diagnosis are mainly based on studies that compared aCGH with karyotype. There is a paucity of reviews that critically appraise the role of SNP array as a prenatal diagnostic tool. We decided to estimate the incremental yield of SNP array over karyotype in detecting chromosomal abnormalities, and to determine the diagnostic accuracy of SNP alone compared with SNP array and karyotype in combination for prenatal diagnosis in fetuses with an abnormal ultrasound.

Study design, size, duration

We conducted a systematic review of studies comparing SNP array with karyotype for prenatal diagnosis in fetuses with an abnormal ultrasound. We performed a literature search in the electronic databases of EMBASE, PubMed, CENTRAL, CDSR, SCOPUS and Web of science for relevant studies published in the English language between January1996 and May 2020. We also hand searched the referenced list of included studies and performed a google search for grey literature to identify potential studies.

Participants/materials, setting, methods

The study population was women undergoing prenatal diagnosis for abnormal fetal ultrasound. Studies in which SNP array and karyotyping had been used in fetuses with abnormal ultrasound and which allowed for a 2 x 2 data extraction table were included. We estimated the incremental yields for SNP array over karyotype. For determining the diagnostic accuracy, we considered SNP array alone as the index test and combined karyotype & SNP array as the reference standard.

Main results and the role of chance

We included six studies for quantitative analysis. After pooling results, incremental yield of SNP array over normal karyotype was 10% (95% confidence interval, CI 4 to 16%) in fetuses with abnormal ultrasound while incremental yield of karyotype over SNP array was 1% (95% CI 0 to 2%). The agreement between SNP array and karyotype was 92%. Variant of uncertain significance (VUS) rates ranged from 4–8%.

For SNP array alone versus combined SNP array and conventional karyotype, pooled sensitivity and specificity was 0.96 (95% CI 0.91 to 0.99) and 1.00 (95% CI 0.99 to 1.00) respectively. The Area under curve (AUC) was 0.99 indicating the discriminating ability of the SNP array was very high to identify the fetus with chromosomal abnormalities.

Limitations, reasons for caution

Only studies published in English were included. There was some degree of heterogeneity in inclusion criteria for the included studies.

Wider implications of the findings: The current study suggests SNP array alone can replace conventional karyotype for prenatal diagnosis in fetus with an abnormal ultrasound. Limitations to adoption of SNP testing might include the requirement of requisite expertise to interpret the results and counsel patients appropriately, especially with the propensity of SNPs to identify VUS.

Trial registration number

Not applicable

Live birth and perinatal outcomes using cryopreserved oocytes: an analysis of the Human Fertilisation and Embryology Authority database from 2000 to 2016 using three clinical models

STUDY QUESTION

Are live birth (LB) and perinatal outcomes affected by the use of frozen own versus frozen donor oocytes?

SUMMARY ANSWER

Treatment cycles using frozen own oocytes have a lower LB rate but a lower risk of low birth weight (LBW) as compared with frozen donor oocytes.

WHAT IS KNOWN ALREADY

A rising trend of oocyte cryopreservation has been noted internationally in the creation of donor oocyte banks and in freezing own oocytes for later use in settings of fertility preservation and social egg freezing. Published literature on birth outcomes with frozen oocytes has primarily utilised data from donor oocyte banks due to the relative paucity of outcome data from cycles using frozen own oocytes.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study utilising the anonymised database of the Human Fertilisation and Embryology Authority, which is the statutory regulator of fertility treatment in the UK. We analysed 988 015 IVF cycles from the Human Fertilisation and Embryology Authority (HFEA) register from 2000 to 2016. Perinatal outcomes were assessed from singleton births only.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Three clinical models were used to assess LB and perinatal outcomes: Model 1 compared frozen own oocytes (n = 632) with frozen donor oocytes (n = 922); Model 2 compared frozen donor oocytes (n = 922) with fresh donor oocytes (n = 24 706); Model 3 compared first cycle of fresh embryo transfer from frozen donor oocytes (n = 917) with first cycle of frozen embryo transfer created with own oocytes and no prior fresh transfer (n = 326). Preterm birth (PTB) was defined as LB before 37 weeks and LBW as birth weight <2500 g. Adjustment was performed for confounding variables such as maternal age, number of embryos transferred and decade of treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

The LB rate (18.0% versus 30.7%; adjusted odds ratio (aOR) 0.61, 95% CI 0.43-0.85) and the incidence of LBW (5.3% versus 14.0%; aOR 0.29, 95% CI 0.13-0.90) was significantly lower with frozen own oocytes as compared with frozen donor oocytes with no significant difference in PTB (9.5% versus 15.7%; aOR 0.56, 95% CI 0.26-1.21). A lower LB rate was noted in frozen donor oocyte cycles (30.7% versus 34.7%; aOR 0.69, 95% CI 0.59-0.80) when compared with fresh donor oocyte cycles. First cycle frozen donor oocytes did not show any significant difference in LB rate (30.1% versus 19.3%; aOR 1.26, 95% CI 0.86-1.83) or PTB, but a higher incidence of LBW (17.7% versus 5.4%; aOR 3.77, 95% CI 1.51-9.43) as compared with first cycle frozen embryos using own oocytes.

LIMITATIONS, REASONS FOR CAUTION

The indication for oocyte freezing, method of freezing used (whether slow-freezing or vitrification) and age at which eggs where frozen were unavailable. We report a subgroup analysis of women using their own frozen oocytes prior to 37 years. Cumulative LB rate could not be assessed due to the anonymous nature of the dataset.

WIDER IMPLICATIONS OF THE FINDINGS

Women planning to freeze their own eggs for fertility preservation or social egg freezing need to be counselled that the results from frozen donor egg banks may not completely apply to them. However, they can be reassured that oocyte cryopreservation does not appear to have a deleterious effect on perinatal outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was sought for the study. The authors have no relevant conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Evaluation of a Pilot Vancomycin Precision Dosing Advisory Service on Target Exposure Attainment Using an Interrupted Time Series Analysis

This study evaluated the ability of a pilot therapeutic drug monitoring (TDM) Advisory Service to facilitate vancomycin therapeutic target attainment within a real-world clinical setting. The Service provided area under the concentration-time curve (AUC)-guided vancomycin dose recommendations, using Bayesian forecasting software and clinical expertise, to prescribers at an Australian hospital. A retrospective audit of intravenous vancomycin therapy (> 48 hours) in adults (≥ 18 years old) was undertaken over a 54-month period to evaluate attainment of established vancomycin pharmacokinetic/pharmacodynamic targets (AUC over 24 hours / minimum inhibitory concentration: 400-600) before (36-month period) and after (18-month period) Service implementation. Interrupted time series analysis was employed to evaluate monthly measures of the median proportion of therapy spent within the target range. Indices of time to target attainment were also assessed before and after Service implementation. The final cohort comprised 1,142 courses of vancomycin (816 patients); 835 courses (596 patients) and 307 courses (220 patients) administered before and after Service implementation, respectively. Prior to piloting the Service, the median proportion of time in the target range was 40.1% (95% CI, 34.3-46.0%); this increased by 10.4% (95% CI, 1.2-19.6%, P = 0.03) after the Service, and was sustained throughout the post-Service evaluation period. Post-Service target attainment at 48-72 hours after initiation of therapy was increased (7.8%, 95% CI, 1.3-14.3%, P = 0.02). The findings of this study provide evidence that a consultative TDM Service can facilitate attainment of vancomycin therapeutic targets; however, optimization of the Service may further improve the use of vancomycin.

Awareness of Breast Cancer among Surgical Patients in a Tertiary Hospital in Malaysia

Background:

Breast cancer is the commonest cancer among women worldwide. About one in nineteen women in Malaysia are at risk, compared to one in eight in Europe and the United States. The objectives of this study were: (1) to assess patients’ knowledge on risk factors, symptoms and methods of screening of breast cancer; and (2) to determine their perceptions towards the disease treatment outcomes.

Methods:

A cross-sectional survey using a validated self-administered questionnaire was conducted among 119 consecutive surgical female patients admitted from 1st of September to 8th of October 2015 in Hospital Sultan Abdul Halim, Kedah. Data were analyzed using General linear regression and Spearman’s correlation with Statistical Package for Social Science (SPSS) version 20.

Results:

Mean (SD) age was 40.6 (15.1) years and majority of the patients were Malay (106, 89.1%). Mean scores for general knowledge, risk factors and symptoms of breast cancer were 50.2 (24.0%), 43.0 (22.9%) and 64.4 (28.4%) respectively. Mean total knowledge score was 52.1(19.7%). 80 (67.2%) and 55 (46.2%) patients were aware of breast self-examination and clinical breast examination recommendations, respectively. Generally, patients had positive perceptions towards breast cancer treatment outcomes. However, majority (59.7%) considered that it would be a long and painful process. Knowledge was significantly better among married women with spouses (p=0.046), those with personal history of breast cancer (p=0.022) and with monthly personal income (p=0.001) with the coefficient of determination, R²=0.16. Spearman’s correlation test showed a significant positive relationship between monthly personal income and breast cancer awareness (r = 0.343, p <0.001).

Conclusion:

Awareness on breast cancer among our patients was average. Thus, there is a need for more awareness programs to educate women about breast cancer and promote its early detection.

Oral nifedipine versus intravenous labetalol for severe hypertension during pregnancy: a systematic review and meta-analysis

BACKGROUND

Oral nifedipine is recommended along with labetalol and hydralazine for treatment of severe hypertension during pregnancy by most authorities. Although nifedipine is cheap and easily administered, the usage pattern among health care providers suggests a strong preference for labetalol despite lack of evidence for the same.

OBJECTIVES

To determine the efficacy and safety of oral nifedipine for treatment of severe hypertension of pregnancy compared with intravenous labetalol.

SEARCH STRATEGY

We systematically searched for articles comparing oral nifedipine with intravenous labetalol for the treatment of severe hypertension during pregnancy in any language, over Medline, Cochrane Central Register of Clinical Trials and Google Scholar from inception till February 2014.

SELECTION CRITERIA

We included all RCTs that compared intravenous labetalol with oral nifedipine for treatment of severe hypertension during pregnancy, addressing relevant efficacy and safety outcomes.

DATA COLLECTION AND ANALYSIS

Eligible studies were reviewed, and data were extracted onto a standard form. We used Cochrane review manager software for quantitative analysis. Data were analysed using a fixed effect model.

MAIN RESULTS

The pooled analysis of seven trials (four from developing countries) consisting of 363 woman-infant pairs showed that oral nifedipine was associated with less risk of persistent hypertension (RR 0.42, 95% CI 0.18-0.96) and reported maternal side effects (RR 0.57, 95% CI 0.35-0.94). However, on sensitivity analysis the outcome 'persistent hypertension' was no longer significant. Other outcomes did not reach statistical significance.

CONCLUSION

Oral nifedipine is as efficacious and safe as intravenous labetalol and may have an edge in low resource settings.

TWEETABLE ABSTRACT

Although studies to date are few in number and small, nifedipine shows promise for severe hypertension in pregnancy.

An evaluation of consumers' perceptions regarding "modern medicines" in penang, malaysia

The objective of this study was to evaluate consumers' perceptions regarding "modern medicines" in Penang, Malaysia. To conduct this exploratory study, qualitative techniques were used. Consumers more than 19 years of age and could speak English, who had visited a pharmacy in the last 30 days, were included from the four major areas of Penang. Eighteen interviews were conducted until the point of saturation. The interviews were audio-taped and then transcribed verbatim for thematic content analysis. Many consumers correctly identified the major characteristics and properties of modern medicines; however, others raised doubts regarding the safety, quality and efficacy of "modern medicines". There were many misconceptions such as "all modern medicines can cause dependence", traditional medicines are completely "free of side-effects" and "Western medicines cure while Chinese medicines don't". Color was also considered a strong determinant of the safety and characteristics of a medicine. Regarding consumers' "medicine information seeking behavior", many consumers would seek information from doctors and pharmacists; however, there were others, who would look for books, or get it from the internet and friends. Of concern many consumers emphasized that while "self-searching for drug information" they would only look for side-effects. Misconceptions regarding medicine-taking behavior, medicine use and compliance were also identified. Though several consumers complied with the medicine-taking instructions, many reported that they would stop taking medicines, once they feel better. Though many consumers correctly identified the characteristics of "modern medicines", misconceptions regarding "medicine information sources and "medicine-taking behavior" were rampant. The situation demands corrective actions including community-oriented educational campaigns to improve "medicine use" in the society.